Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Wednesday, September 23, 2009

Doctor Payment Reform

It's the holy grail of physician payment reform: ending fee-for-service payments to doctors and, instead, pay doctors based on the quality of care they perform. Remarkably, Congress feels they've found the answer:

Thus, the new language in the Senate Finance bill would finally connect Medicare reimbursements to quality, as opposed to volume.

The measure gives the secretary of Health and Human Services, working with the Centers for Medicare and Medicaid Services, the power to develop quality measurements and a payment structure that would be based on quality of care relative to the cost of care. The secretary would have to account for variables that include geographic variations, demographic characteristics of a region, and the baseline health status of a given provider's Medicare beneficiaries.

The secretary would also be required to account for special conditions of providers in rural and underserved communities.

Additionally, the quality assessments would be done on a group-practice level, as opposed to a statewide level. Thus, the amendment would reward physicians who deliver quality health care even if they are in a relatively low quality region.

The secretary of Health and Human Services would begin to implement the new payment structure in 2015. By 2017, all physician payments would need to be based on quality.

Medicare has historically withheld payments to physicians unless they performed lock-step "quality measures" before granting release of the remainder of 1.5 percent of the doctors' payments that were billed. Needless to say, this model has been an abysmal failure (subscription) at improving the "quality" of care delivered and has been very expensive to implement. Further, others have noted the challenge of measuring quality on the basis of clinical outcomes.

But this has not dissuaded our legislators from forcing the "quality issue." No, they have proposed to find a fix by the creation of a hugely expensive C.M.S. Innovations Center:

"It would be funded with $10 billion over the next several years to implement pilot projects and demonstrations to promote new payment reform opportunities. There are quite a few problems with the bill, but this provision is truly visionary. The House legislation, HR 3200, mentions payment reform, but it [provides] only modest funding of $275 million. That’s not enough.

I suppose $10 billion compared to $275 million is "truly visionary" if you stand to receive the funds. One wonders what the tax payers will get at the end of the day for this grotesque amount of money.

Perhaps I'm too cynical, but I think the subliminal message coming from Washington so far is really this: doctors should be happy becoming salaried employees of larger health systems. This way, the government can pay the health system a bundled fee and the doctors can fight for their share of the kitty.

So far, this seems to be how the government will envision "quality" at an affordable price in the years to come.

How are we going to reward physicians for delivering better "quality care" in this new system is the question. If your personal attempt at quality care is diluted out by actions of the health care system that employs you the hospital you are affiliated with, then what are your choices? To move to a system with better quality data and thus payment?

Putting this in place so all health care services are essentially bundled will be extremely difficult, and I suspect in the division of the pie, there will be great incentives to maintain the staus quo. How and who will determine the division of this money in each health care institution? If it is the hospital, watch out!

That being said we do need some sane system where one is rewarded for keeping patinets healthy and not one that encourages more tests and procedures to be performed. I just don't know how to get there.

Objective assessment of quality in an environment of privacy seems impossible to my eye. Right now, the only way we have our quality measured is by ticking off checklists that bear little resemblance to the nuances of delivering good medical care.

Do you really think you could assessment the quality of care delivery of one of your own partners, even, without participating in the interview and assessment process yourself.

I'm thinking that the last time the quality of my care was truly well assessed was when I was an intern or resident. In that model, the evaluator were able to get into the "trenches" and really see what needed to be done and how to do it.

Modern medicine is a non-hiarachical system with privacy laws. I think if there was some way to break down these barriers, we might know what each of us was up to.

Perhaps as medicine moves to a more employer/employee model (i.e. with hospital ownership of practices), we could find a way other than the malpractice courts and CMS police to assess the quality of care delivery. I for one would welcome the opportunity to showcase my care to separate from those who go about things in a half assed manner.

The article you referenced is already linked in this piece. The ACC and Dr. Lewin must remember that 85% of doctors are presently NOT part of large hospital groups and the idea of developing "virtual practice groups" that will cost $10 billion to test seems unrealistic to me.

The ACC has been at the forefront of the registry idea to apply retrospective data reviews to improve quality, but whether this concept can be expanded to areas in medicine that are not procedural in nature, but rather intellectual, seems doubtful.

The government is the acknowledged leader in paying for results rather than good intentions. All of Congress and its politicians observe this ruthless truth. The very word "politics" communicates transparency and dedication to unbiased measurement and intelligent standards.

So, of course, all of U.S. medicine will run a whole lot better, cheaper, and faster when these standards are imposed by the masters. We are on the beaches of a new order, ready to migrate inward to a land of rational control. Finally.

Even if it doesn't work, we will learn valuable lessons and data. An entire society is not too much to risk in the pursuit of new knowledge. An entire generation of earnings is not too much to distribute in this pursuit of the new man.

Why is government the ideal director of medicine? Because we see in Politicians a dedication to thoughtfullness, care, and altruism. Their lives are devoted to helping others. Contrast this to Physicians, who have spent half their lives learning complex and expensive procedures, with the intent of charging sick people for their services.

In West Michigan a group of physicians, business people, and citizens with interest in health care quality under the guidance of the Alliance for Health, a regional non-profit, are building a set of quality criteria. This effort is being funded by the Robert Wood Johnson Foundation in its Aligning Forces for Quality. It will be interesting to see if quality can be regionally defined.

My practice was contacted by the ACC because we have a pretty good EMR. They wanted us to participate in a project to test a new check list of best practice guidelines using the our EMR -- they estimated it would add between 5-10 minutes per patient.

Also read they want to equate reimbursement to "results," like weight loss or smoking cessation. Paid more if our patients quit. Can you imagine what is going to happen to our sick / non compliant patients? Doctors will be forced to drop them or else provided free care to the most time consuming patients.

As a current young physician that practices cost effective medicine, perhaps "anonymous" is correct, we will need a whole new generation of physicians that don't care about their pocketbook. Be careful, you may get exactly what you are asking for....

It only stands to reason that health care costs will drop dramatically when the hospital as an employer has more control of physicians (employees) i.e. administrators will determine physician salaries. I can't imagine administrators rewarding those physicians who admit more patients or perform more procedures. Quality care equates with the avoidance of hospital admissions.

Logically, those physicians who generate the least revenue for the hospital may typically be providing the best quality.

Thanks for reading my interview with the Times, Dr. Wes. And be sure to check out my follow up comments on The Lewin Report (http://lewinreport.acc.org). There’s no question… defining ‘quality’ is an exercise best left to those on the front lines of care delivery – our physicians. And that’s why the CMS Innovations Center can be such a valuable tool in our push for payment reform. It may be expensive, but if properly staffed, it could help inject new evidence and guidelines into the health care system, give physicians another performance benchmark, and provide valuable clinical decision support so we can halt unnecessary admissions, readmissions or inappropriate imaging. Thanks again for your thoughts!

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.